Diagnosis and management of third nerve palsy

Ocular Motor Mononeuropathies in Diabetes Mellitus: A Brief Review

Ocular motor mononeuropathies affect cranial nerves III, IV and VI and are more frequent in diabetes mellitus, with oculomotor nerve involvement being predominant. This narrative brief review discusses the clinical manifestations, diagnosis and management of ocular motor mononeuropathies in subjects with diabetes. Clinical manifestations often include ptosis, diplopia, and periorbital pain. Pupillary sparing is a characteristic of third nerve palsy. Differential diagnosis may be challenging due to overlapping symptoms with nerve palsies of other aetiologies. Treatment includes optimised glycaemic control and management of vascular risk factors. Neuroprotective agents, mainly alpha-lipoic acid and botulinum toxin A have been occasionally used, as well. Spontaneous recovery is seen in many cases.

Clinical features and surgical management of traumatic acquired isolated superior rectus palsy

PURPOSE

Isolated acquired superior rectus palsy (ASRP) is extremely rare. The goal of this report is to describe the clinical manifestations and surgical protocols for treatment of isolated traumatic ASRP.

DESIGN

Retrospective observational case series.

METHOD

Records of patients presenting with traumatic isolated ASRP from 2011 to 2020 were retrospectively reviewed. Variables analyzed included nature of the damage, ocular alignment, ocular motility, binocular vision, fundus photography, imaging and surgical treatment.

RESULT

Of the 23,498 strabismus surgeries performed, 16 (0.07%) were identified as being attributable to traumatic isolated ASRP. Iatrogenic injury during orbital/brain tumorectomy was the most common cause for ASRP, followed by injury resulting from a sharp object, blunt instrument, car accident, dog bite, accidental fall and explosion. The main clinical features were hypotropia and deficient supraduction of the affected eye, accompanied by exotropia, extorsion, decreased vision and ptosis. The imaging examination showed the superior orbital wall fracture in 3 cases and superior rectus rupture in 7 cases. Inferior rectus recession and/or superior rectus resection comprised the major surgical procedures employed for these cases. Vertical deviations were reduced from 45.60 ± 17.52 PD preoperatively to 12.20 ± 12.97 PD postoperatively after an average of 22.70 months at follow-up, with a success rate of 50%.

CONCLUSION

Traumatic isolated ASRP comprised only 0.07% of cases receiving strabismus surgery at our hospital. Orbital imaging is essential to identify whether muscle rupture, orbital fractures and/or other possible disorders are present. Superior rectus resection and inferior rectus recession represented the most frequently used surgical procedures.

Surgical management of oculomotor nerve palsy - a review of the literature

We aim to review the surgical management techniques available for patients with oculomotor nerve (OMN) palsy, compare and contrast the approaches and subsequent outcomes. A search of the literature was carried out to yield all papers relevant to the topic, and a wide spectrum of surgical techniques were identified. These included: muscle shortening and lengthening procedures, muscle transposition, globe fixation and ptosis surgery. Patients often require a synergistic combination of these techniques. Strabismus surgery for OMN palsy can be approached through a variety of different techniques to improve the quality of life, independence and aesthetics for the patient.

Etiological distribution of isolated oculomotor nerve palsy: analysis of 633 patients and literature review

BACKGROUND AND PURPOSE

The etiological distribution of oculomotor nerve palsy has varied amongst the studies. This study aimed to define the clinical features and underlying etiologies of isolated oculomotor nerve palsy by recruiting patients from all departments in a referral-based university hospital.

METHODS

The medical records of 672 patients who had a confirmed diagnosis of isolated oculomotor nerve palsy at all departments of Seoul National University Bundang Hospital, Seongnam, South Korea, from 2003 to 2020 were reviewed. A proportion of the etiology of isolated oculomotor nerve palsy was also compared with that of patients pooled from the previous studies that were searched on PubMed in May 2022.

RESULTS

The most common etiology was microvascular (n = 168, 26.5%), followed by vascular anomalies (n = 110, 17.4%), neoplastic (n = 86, 13.6%), inflammatory (n = 79, 12.5%), idiopathic (n = 60, 9.5%) and traumatic (n = 53, 8.4%). Neurologists were mainly involved in the management of microvascular and inflammatory oculomotor nerve palsies whilst ophthalmologists mainly participated in the care of idiopathic, neoplastic and traumatic palsies. Neurosurgeons mostly took care of oculomotor nerve palsy due to vascular anomalies.

CONCLUSIONS

The proportion of etiologies of isolated oculomotor nerve palsy may differ according to the specialties involved in the management. The results of previous studies on the etiological distribution of isolated oculomotor nerve palsy should be interpreted with this consideration.

Acupuncture therapy for isolated ischemic oculomotor nerve palsy: A case report

BACKGROUND

Isolated ischemic oculomotor nerve palsy as a type of ophthalmic disease is rarely observed in clinical practice. Quality of life is frequently impacted by isolated ischemic oculomotor nerve palsy due to its lack of treatment options and long-term visual impairment. We describe an acupuncture-treated instance of isolated ischemic oculomotor paralysis.

METHODS

Acupoints including Jingming (BL 1), Chengqi (ST 1), Cuanzhu (BL 2), and Sizhukong (TE 23) on the right side, and bilateral Fengchi (GB 20), Waiguan (TE 5), Hegu (LI 4), and Zulinqi (GB 41) were selected for needling. Each treatment lasted for 30 minutes, once every other day. Acupuncture treatment was administered for a total of 11 times.

RESULTS

Acupuncture is a promising treatment option for isolated ischemic oculomotor nerve palsy.

CONCLUSIONS

Ischemic oculomotor nerve paralysis can affect the quality of life of patients. Acupuncture intervention can promote the recovery of the disease is a very effective treatment measure.

Ocular motor nerve palsy in patients with diabetes: High-resolution MR imaging of nerve enhancement

OBJECTIVE

To evaluate the extent of signal abnormality in impaired ocular motor nerves using high signal and spatial resolution MRI sequences and to discuss the involvement of inflammatory or microvascular impairment in patients with diabetic ophthalmoplegia.

METHODS

We conducted a retrospective study of 10 patients referred for acute ocular motor nerve palsy in the context of diabetes mellitus from September 15th, 2021 to April 24th, 2022. 3T MRI evaluation included diffusion, 3D TOF, FLAIR, coronal STIR and post-injection 3D T1 SPACE DANTE sequences.

RESULTS

Ten patients were included: 9 males and 1 female aged from 46 to 79 years. Five patients presented with cranial nerve (CN) III palsy, and 5 presented with CN VI palsy. Third nerve palsy was pupil-sparing in 4 patients and pupil-involved in 1 patient. Pain was associated in all patients with CN III deficiencies and in 2 patients CN VI deficiencies. In all patients, MRI sequences ruled out mass effect and vascular pathology, such as acute stroke or aneurysm. Eight patients presented with STIR hypersignals, some with enlargement of the involved nerve. The diagnosis was confirmed through a post-injection 3D T1 SPACE DANTE sequence, which showed extended enhancement along the abnormal portion of the nerve.

CONCLUSION

High-resolution MRI evaluation of diplopia in diabetic patients is used to rule out a diagnosis of acute stroke and contributes to the positive diagnosis of ocular motor nerve impairment, possibly combining the influences of inflammatory and microvascular phenomena. Dedicated MR imaging should be included in the initial diagnosis and longitudinal follow-up of patients with diabetic ophthalmoplegia.

Ocular Motor Nerve Palsy After Traumatic Brain Injury: A Claims Database Study

BACKGROUND

Traumatic brain injury (TBI) is one of the common causes of ocular motor nerve (oculomotor nerve [CN3], trochlear nerve [CN4], and abducens nerve [CN6]) palsies, but there has been no large study of ocular motor nerve palsy caused by TBI. This study aimed to investigate the characteristics of and differences in ocular motor nerve palsy after TBI, according to patient age and severity of TBI.

METHODS

This was a population-based retrospective cohort study that included patients who had ocular motor nerve palsy after TBI with ≥6 months of continuous enrollment using claims data from the IBM MarketScan Research Databases (2007-2016). We assessed sex, age at the first diagnosis of TBI, the severity of TBI, and the rates of strabismus procedures according to the age and severity of TBI. The rates of muscle transposition surgery and chemodenervation in CN3, CN4, and CN6 palsy were investigated.

RESULTS

A total of 2,606,600 patients with TBI met the inclusion criteria. Among them, 1,851 patients (0.071%) had ocular motor nerve palsy after TBI. The median age of the patients was 39 (Q1-Q3: 19-54) years, and 42.4% of the patients were female. The median continuous enrollment period after the first diagnosis of TBI was 22 (Q1-Q3: 12-38) months. Of the 1,350,843 children with TBI, 454 (0.026%) had ocular motor nerve palsy. Of the 1,255,757 adults with TBI, 1,397 (0.111%) had ocular motor nerve palsy. Among these 1,851 patients, CN4 palsy (697, 37.7%) occurred most frequently, and strabismus procedures were performed in 237 patients (12.8%). CN6 palsy developed most frequently in children. More children (16.5%) underwent strabismus surgeries than adults (11.6%) ( P = 0.006). The proportion of CN4 palsy (52.3%) was higher while the proportion of CN3 palsy (15.5%) was lower in patients with mild TBI than in patients with moderate-to-severe TBI ( P < 0.001).

CONCLUSIONS

CN4 palsy developed most frequently among patients of all ages, and only approximately 13% of the patients underwent strabismus procedures for ocular motor nerve palsy after TBI. The rate of development of ocular motor nerve palsy was approximately 4.3 times lower in children than adults, and children most frequently had CN6 palsy after TBI.

Internal carotid artery aneurysm with incomplete isolated oculomotor nerve palsy: a case report

BACKGROUND

Oculomotor nerve palsy is a common and well-described disease with diverse etiologies. Clinicians should quickly and correctly diagnose and treat oculomotor nerve palsy according to its characteristics and the accompanying symptoms and signs. Intracranial aneurysm is an important and frequent cause of oculomotor nerve palsy. Considering the catastrophic consequences of rupture, the possibility of an urgent, life-threatening disease should always be considered.

CASE PRESENTATION

A 63-year-old Chinese woman presented with intermittent left ptosis and diplopia and painless incomplete oculomotor nerve palsy without pupil involvement. She manifested no mydriasis or extraocular muscle weakness, and the light reflex was normal. Other cranial nerves and somatosensory and somatomotor examinations were normal. The neostigmine experiment and electromyography were normal, so the diagnosis of myasthenia gravis was excluded. Brain magnetic resonance angiography showed a 4-mm aneurysm located at the cavernous segment of the left internal carotid artery. Unfortunately, the patient refused digital subtraction angiography and was discharged home without further treatment.

CONCLUSION

Neuroimaging must be performed to exclude intracranial aneurysms in oculomotor nerve palsy regardless of whether the pupils are involved, as aneurysm rupture carries substantial morbidity and mortality.

Efficacy and long-term results of endovascular embolization and surgical clipping for posterior communicating artery unruptured aneurysms complicated with oculomotor nerve palsy

to investigate the efficacy and long-term outcomes of endovascular embolization and surgical clipping for patients with posterior communicating artery unruptured aneurysms (PcomAs) concomitant with oculomotor nerve palsy (ONP). No significant (P > .05) difference existed in the age, gender, proportion of complete ONP, and size of eye fissure and pupil before treatment between 2 groups. After compared with before treatment, the eye fissure was widened significantly (P < .05) and the pupil narrowed significantly (P < .05), but no significant (P > .05) differences existed between the 2 groups. Complete ONP recovery was observed in 32 (80%) patients in the embolization group and 31 (77.5%) in the microsurgical group, partial ONP recovery occurred in 6 (15%) in the embolization group and 8 (20%) in the microsurgical group. The recovery rate was 95% in the embolization group and 97.5% in the microsurgical group, with no significant (P > .05) difference between 2 groups. The recovery rate of the ONP was significantly (P < .01) greater in the microsurgical group than that in the embolization group at follow-up of 1 month, 3 months, six and 12 months, respectively. At 18 months, the ONP recovery rate was not significantly different between 2 groups (95% vs 97.5%) Surgical clipping may have a faster effect on the recovery of oculomotor nerve palsy than endovascular embolization for patients with posterior communicating artery unruptured aneurysms complicated with oculomotor nerve palsy, but both approaches may result in a similar effect on the nerve recovery in the long run.Eighty patients treated with endovascular embolization or surgical clipping were retrospectively enrolled into the endovascular embolization group or surgical clipping and analyzed.

[Management of ptosis]

Ptosis is defined as a drooping of the upper eyelid. It often results in functional and/or aesthetic impairment. Although often benign, ptosis may be the first symptom of a life-threatening condition (carotid dissection, intracranial aneurism, generalized myasthenia). Only a rigorous, systematic and clinical examination will allow the physician to distinguish "benign ptosis" from "urgent ptosis". The history should attempt to detect a daily variation in the ptosis, suggesting myasthenia gravis. Pupillary examination should rule out myosis, which would suggest Claude Bernard-Horner's syndrome (secondary to an internal carotid dissection until proven otherwise), or mydriasis, suggesting an intracranial aneurism. Once an emergency has been ruled out, the clinical examination should assess the levator muscle strength (helpful for determining the underlying etiology) and the Bell's phenomenon (the lack of which is predictive of postoperative corneal exposure). The amount of ptosis is not related to its etiology. At the conclusion of the examination, the physician must be able to classify the ptosis as either pseudoptosis, aponeurotic ptosis, neurogenic ptosis, myogenic ptosis, or junctional ptosis (myasthenia). Except for "urgent ptosis", requiring multidisciplinary medical treatment, surgery is the mainstay of treatment. The surgical technique is based on the etiology of the ptosis, the strength of the levator muscle and the phenylephrine test.

Neurosyphilis masquerading as oculomotor nerve palsy in a healthy middle-aged man: Case report and review of the literature

Acquired isolated oculomotor nerve palsy (ONP) is a commonly encountered clinical entity in ophthalmology. While most cases are due to microvascular ischemia, the diagnosis of ONP requires careful evaluation for alternate life-threatening etiologies. We present a case of isolated complete pupil-involving ONP in a healthy 47-year-old man in whom aneurysmal compression was initially suspected. Investigations later revealed a diagnosis of neurosyphilis. Neurosyphilis is an extremely rare cause of isolated ONP and seldom reported in the literature. Timely recognition of this disease by ophthalmologists can help orient patients to the appropriate neurology and infectious disease services they need.

Comparison of surgical clipping and endovascular coiling in the treatment of oculomotor nerve palsy caused by posterior communicating artery aneurysm

Oculomotor nerve palsy (ONP) caused by posterior communicating aneurysm (PcomAA) is mainly treated by surgical clipping or endovascular coiling. However, there are still some controversies about which treatment method could provide the more beneficial prognosis. This study aimed to compare ONP recovery rate between surgical clipping and endovascular coiling in patients diagnosed as PcomAA combined with ONP, and explore the potential risk factors of ONP recovery.The clinical data of 152 patients with ONP caused by PcomAA were retrospectively analyzed. Diameter of aneurysm, different treatment methods (surgical clipping or endovascular coiling), subarachnoid hemorrhage (SAH), degree of preoperative ONP, time from ONP onset to treatment, as well as degree of ONP symptom recovery were collected from medical records. All patients were followed up for at least 1 year.One hundred twelve patients underwent surgical clipping and 40 patients received endovascular coiling. There were no significant differences in age, gender, aneurysm diameter, hypertension, dyslipidemia, time from ONP symptom onset to treatment, SAH, and preoperative ONP degree between the 2 groups (all P > .05). Time to complete or partial recovery was 86.7 ± 35.7 days for patients receiving surgical clipping and 132.6 ± 37.5 days for patients receiving endovascular coiling, respectively (Log rank test, P < .001). The recovery rate was 94.6% in the surgical clipping group and 65.0% in the endovascular coiling group. The difference between the two groups was statistically significant (P < .001). Postoperative ONP recovery in the surgical clipping group was significantly superior to that of patients in the endovascular coiling group (HR, 2.625; 95% CI: 1.423-4.841; P = .002). Time from ONP symptom onset to treatment exerted the obvious effect on the ONP prognosis (HR, 0.572; 95% CI: 0.384-0.852; P = .006). In addition, the ONP recovery in patients with SAH before surgery was also independently associated with ONP prognosis (HR, 1.276; 95% CI, 1.043-1.562; P = .018). There was no treatment-related death in either group, and postoperative complications were within the manageable range.The recovery rate and recovery degree of ONP after surgical clipping was significantly better than that of endovascular coiling in PcomAA patients combined with ONP. The postoperative ONP recovery was associated with preoperative spontaneous SAH and time from ONP onset to treatment.

Recovery of posterior communicating artery aneurysm induced oculomotor nerve palsy: a comparison between surgical clipping and endovascular embolization

BACKGROUND

Oculomotor nerve palsy (ONP) is a common symptom of posterior communicating artery aneurysm (PcomAA) that can lead to impaired eye movement and pupil dilation. Currently, surgical clipping and endovascular embolization are the two most popular treatment methods for PcomAA-induced ONP; however, the recovery outcome between the two methods remains to be elucidated.

METHODS

In the present study, we thoroughly compared the pretreatment factors and recovery outcome of the two treatments on 70 patients with PcomAA-induced ONP. The patients were separated into two groups based on the treatment that was received. Pretreatment factors, including age, sex, time period between ONP onset and treatment, ONP type, aneurysm diameter, status of subarachnoid hemorrhage and aneurysm rupture were recorded for each individual patient. Recovery outcome of the patients was assessed over a 12-month period.

RESULTS

No significant differences were observed in any of the analyzed factors. Importantly, we revealed a significantly higher full recovery rate for the patients receiving the surgical clipping treatment than the ones that received the endovascular embolization treatment. In addition, we showed that patients' age was negatively correlated with the recovery extent in both treatment groups.

CONCLUSIONS

The outcome of our study suggests that surgical clipping might be a better option to treat PcomAA-induced ONP.

The Incidence and Etiologies of Third Cranial Nerve Palsy in Koreans: A 10-year Nationwide Cohort Study

PURPOSE

This study aimed to determine the incidence, prevalence, and etiologies of third cranial nerve (CN3) palsy in Koreans.

METHODS

Data were collected from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database of South Korea and analyzed. Incident CN3 palsy subjects in the cohort population were defined as cases occurring after the initial 4-year or longer washout period. The incidence and prevalence were analyzed by sex, age group, and year. The etiologies of CN3 palsy were evaluated using comorbidities.

RESULTS

Of 1,108,253 subjects, 387 patients were newly diagnosed with CN3 palsy between 2006 and 2015. The incidence of CN3 palsy was 3.71 per 100,000 person-years (95% confidence interval, 3.35-4.09). The incidence of CN3 palsy increased with age and accelerated after the age of 60 years. The mean male-to-female incidence ratio was 1.16. The main cause was presumed to be vascular disease (52.7%), followed by idiopathic causes (25.8%), intracranial neoplasm (7.8%), unruptured cerebral aneurysm (5.4%), and trauma (5.2%).

CONCLUSIONS

The incidence of CN3 palsy in Koreans increased with age and peaked between 75 and 79 years. The main cause of CN3 palsy was vascular disease.

Guidelines for radiographic imaging of cranial neuropathies

Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Oculomotor palsy as a single presenting sign of midbrain hemorrhage

We report a case presenting with bilateral oculomotor nerve palsy (ONP) resulting from a midbrain hemorrhage. The patient visited the ophthalmological clinic due to the sudden onset of horizontal diplopia for a week. Bilateral ONP spared the left eye levator and bilateral pupils were found while the remaining results of examinations were unremarkable. Cerebral magnetic resonance imaging revealed a midbrain hemorrhage. Mono-ocular occlusion was arranged, and the patient was referred to a neurologist for further management. No further ophthalmic signs developed, but the patient became bedridden due to brainstem hemorrhage and died of aspiration pneumonia 9 months after the onset of the oculomotor signs. It is advocated that midbrain hemorrhage should be included in the differential diagnosis once diplopia develops and that careful neurological investigation of the origin of diplopia is warranted.

Focal and entrapment neuropathies

Of the many patterns of peripheral nerve disorders in diabetes mellitus (DM), isolated clinical involvement of single nerves, though less common than distal symmetric polyneuropathy and perhaps polyradiculoneuropathy, constitute an important collection of characteristic syndromes. These fall into four anatomical regions of the body: cranial, upper limb, truncal, and lower limb territories. Each of these groups of mononeuropathies has its own ensemble of epidemiologic patterns, clinical presentations, laboratory and radiologic findings, differential diagnosis, management principles and prognosis.

Approach to a patient with blepharoptosis

Blepharoptosis or drooping of upper eye lid is a common, but non-specific sign of neurological diseases which sometimes could herald a life-threatening disorder. First, the diagnosis of ptosis should be established by considering four clinical measurements: palpebral fissure height, marginal reflex distance, upper eyelid crease, and levator function test. The diagnostic categories of ptosis are scheduled as pseudo-ptosis, congenital, and acquired ptosis. Acquired causes include mechanical, myogenic, neuromuscular, neurogenic, and cerebral. Each category with diseases presenting with ptosis was described in detail. Considering some features, such as involvement of other cranial nerves, extraocular muscle, pupil size and reactivity, and unilateral or bilateral presentation of ptosis, could help to narrow the differential diagnosis.

Superior Oblique Anterior Transposition with Horizontal Recti Recession-Resection for Total Third-Nerve Palsy

Aims. To report the results of lateral rectus muscle recession, medial rectus muscle resection, and superior oblique muscle transposition in the restoration and maintenance of ocular alignment in primary position for patients with total third-nerve palsy. Methods. The medical records of patients who underwent surgery between March 2007 and September 2011 for total third-nerve palsy were reviewed. All patients underwent a preoperative assessment, including a detailed ophthalmologic examination. Results. A total of 6 patients (age range, 14–45 years) were included. The median preoperative horizontal deviation was 67.5 Prism Diopter (PD) (interquartile range [IQR] 57.5–70) and vertical deviation was 13.5 PD (IQR 10–20). The median postoperative horizontal residual exodeviation was 8.0 PD (IQR 1–16), and the vertical deviation was 0 PD (IQR 0–4). The median correction of hypotropia following superior oblique transposition was 13.5 ± 2.9 PD (range, 10–16). All cases were vertically aligned within 5 PD. Four of the six cases were aligned within 10 PD of the horizontal deviation. Adduction and head posture were improved in all patients. All patients gained new area of binocular single vision in the primary position after the operation. Conclusion. Lateral rectus recession, medial rectus resection, and superior oblique transposition may be used to achieve satisfactory cosmetic and functional results in total third-nerve palsy.

Strabismus

Defining the type of strabismus creates a framework for work-up and management. Comitant esotropia is most commonly a childhood condition treated with glasses and surgery. Comitant exotropia is often a childhood condition that may require surgical correction. Microvascular disease is the most common cause of ocular cranial nerve palsies in adult patients.

A Retrospective Comparison of the Influence of Surgical Clipping and Endovascular Embolization on Recovery of Oculomotor Nerve Palsy in Patients With Posterior Communicating Artery Aneurysms

BACKGROUND:

Oculomotor nerve palsy (ONP) is a common symptom of posterior communicating artery aneurysms (PcomAAs). Surgical clipping and endovascular embolization are used to treat PcomAAs with ONP.

OBJECTIVE:

To analyze the impact of these 2 techniques on recovery of ONP caused by PcomAAs.

METHODS:

The clinical data for 176 patients with intracranial PcomAAs with ONP admitted to the Department of Neurosurgery, Sichuan Provincial People's Hospital, between June 2008 and May 2013 who undergone surgical clipping or endovascular embolization were studied retrospectively. The 2 treatment groups were compared with respect to age, sex, aneurysm size, levels of hypertension and hyperlipidemia, preadmission ONP duration, subarachnoid hemorrhage (SAH), complete ONP, postoperative recovery time from ONP symptoms, and degree of recovery. The follow-up duration was a minimum of 12 months. Multivariate Cox regression was used for analysis.

RESULTS:

A total of 132 patients were treated by surgical clipping, and 44 were treated by endovascular embolization. Significant differences were found in postoperative recovery time (83.87 ± 34.70 days for clipping and 137.45 ± 44.94 days for embolization, P &lt; .001) and recovery rates (130 [98.5%] for clipping and 30 [68.2%] for embolization, P &lt; .001). The period between ONP onset and admission was associated with recovery. Postoperative complications included significant cerebral vasospasms (6 in the clipping group and 2 in the embolization group) and hydrocephalus (16 in the clipping group and 9 in the embolization group).

CONCLUSION:

Simultaneous elimination of 2 injury mechanisms, compression and pulsation, when treating the oculomotor nerve by surgical clipping may be more advantageous than endovascular embolization to treat ONP caused by PcomAA.

Treatment of ocular motor palsies

OPINION STATEMENT

The management of ocular motor palsies first requires careful determination of the etiology. Possibilities include ischemia, inflammation, infection, trauma, compression, or congenital. Prognosis for recovery varies greatly between etiologies; hence, determination of the underlying process is crucial in the short- and long-term management of these patients. Naturally, our ultimate goal is to improve visual function as much as possible. A guiding principle in the initial management of ocular motor palsies is to improve patient comfort and visual function by eliminating diplopia in primary position while clinically observing the patient for improvement or stability. Offering a definitive treatment which creates the largest possible zone of binocular single vision in primary and reading positions can be undertaken once stability has been demonstrated. In the initial phase after an acute ocular motor palsy has occurred, occlusion of an eye can be used to eliminate diplopia. Options include a patch or applying translucent or satin tape to one of the lenses which prevents diplopia but still lets light through. Alternatively, prismatic correction placed on or ground into spectacles may improve function and restore binocularity in patients with temporary or permanent ocular deviations. This is generally effective for patients with up to 20 to 25 prism diopters (PD) of horizontal misalignment and 10 to 15 PD of vertical. Once a stable misalignment has been demonstrated (several months), a variety of surgical options exist. Use of adjustable sutures, improved suture materials, and surgical techniques has expanded the role and scope of surgery for these patients. Planning the surgical approach is based on residual extraocular muscle function, careful measurements, and assessment of patient expectations.

Intracranial tuberculoma presenting as an isolated oculomotor nerve paresis

BACKGROUND

The differential diagnosis of isolated oculomotor nerve paresis ranges from benign to potentially lethal pathologies. Intracranial tuberculosis (TB), as in the case of this patient, carries a high morbidity and mortality. Early diagnosis is crucial to improve patient outcomes.

CASE REPORT

We present the case of a 46-year-old man with a chief complaint of 5 days of diplopia. His examination was remarkable for right inferolateral exotropia and weakness of the right medial rectus. Due to the neurologic findings, we obtained a computed tomography brain scan, which revealed a ring-enhancing lesion within the central midbrain with vasogenic edema causing mass effect on the cerebral aqueduct. Further evaluation revealed tuberculosis (TB) as the underlying etiology. He was placed on steroids and a four-drug anti-TB regimen with resultant improvement of his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intracranial tuberculoma can present with an isolated oculomotor nerve paresis in the absence of pulmonary or systemic symptoms. This case emphasizes the importance of maintaining a broad differential when investigating isolated oculomotor nerve paresis.

Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms

Pupillary dysfunction, a concerning finding in the neurologic examination of the patient with an acute traumatic brain injury often dictates the subsequent treatment paradigm. Patients were monitored closely with an infrared pupillometer, with NPi technology, for acute changes in pupillary function. NPi technology applies a scalar value to pupillary function. A retrospective chart review was performed of traumatic brain injury patients with acute unilateral pupillary dilation, admitted to Legacy Emanuel Medical Center’s NeuroTrauma Unit, Portland, OR, and followed as outpatients, between January 2012 and December 2013. Clinical exam findings of pupillary size, NPi scores, and brain Magnetic Resonance Imaging and Computed Tomography images were analyzed. Five traumatic brain injury patients were identified with unilateral pupillary dysfunction with long-term follow-up after the initial injury. Each patient was monitored closely in the trauma bay for neurological deterioration with a pupillometer and the clinical exam. Two patients underwent subsequent intracranial pressure monitoring based on a deteriorating clinical scenario, including consistent abnormal unilateral NPi scores. One patient with consistent abnormal NPi scores and an improved clinical exam did not undergo invasive interventions. Two patients showed early improvement in NPi scores correlating with the normalization of their pupillary reactivity. Anisocoria improved in all patients despite concurrent abnormal NPi scores. Magnetic Resonance Imaging and Computed Tomography imaging studies, with a focus on the third nerve, revealed focal abnormalities consistent with the clinical findings. A unilateral blown pupil and abnormal NPi score in a traumatic brain injury patient are not necessarily indicative of intracranial pressure issues, and must be correlated with the entire clinical scenario, to determine the etiology of the third nerve injury and direct potential therapeutic interventions. Early NPi score normalization suggests pupillary function may improve. We found that NPi scores, as a component of the clinical exam, provide a sensitive, noninvasive and quantitative means of following pupillary function acutely and chronically after a traumatic brain injury.

Managing the patient with oculomotor nerve palsy

PURPOSE OF REVIEW

To provide clinically relevant information regarding the evaluation and current treatment options for oculomotor nerve palsies. We survey recent literature and provide some insights into these studies.

RECENT FINDINGS

Recent case reports highlight emerging new causes of oculomotor cranial nerve palsies, including sellar chordoma, odontogenic abscess, nonaneurysmal subarachnoid hemorrhage, polycythemia, sphenoiditis, neurobrucellosis, interpeduncular fossa lipoma, metastatic pancreatic cancer, leukemia, and lymphoma. Surgical studies have focused on modifications and innovations regarding strabismus surgery for this condition. New globe fixation procedures may include fixation to the medial orbital wall by precaruncular and retrocaruncular approaches, apically based orbital bone periosteal flap fixation and the suture/T-plate anchoring platform system.

SUMMARY

Management of oculomotor nerve palsy depends in part upon the underlying cause and anatomical location of the lesion. Careful clinical evaluation and appropriate imaging can identify a definitive cause in most cases. Surgical options depend on the number, extent, and severity of the muscles involved as well as the presence or absence of signs of aberrant regeneration. The clinician should also address issues that arise due to involvement of the pupil and accommodation. Strabismus surgery can be challenging but also rewarding with appropriate selection and staging of procedures.

Oculomotor Nerve Palsy due to an Odontogenic Abscess Originating from the Mandibular Third Molar

We report a case of oculomotor nerve palsy (ONP) as a result of odontogenic infection originating from the third molar, which is considered rare.

Insertion of the dorsal oblique muscle in the dog: an anatomic basis for ventral strabismus associated with oculomotor nerve dysfunction

OBJECTIVE

To describe the insertion of the dorsal oblique (DO) muscle in relationship to the equator of the globe in dogs.

PROCEDURE

The study was conducted on 10 fresh cadaver eyes from five dogs, which were euthanized for disease processes unrelated to ocular disease. A manual vernier caliper was used to determine the calculated measurements.

RESULTS

The median anterior-to-posterior diameter of the globe was 21 mm. The median length from the vertex of the anterior pole to the anterior point of insertion of the DO tendon was 11.5 mm. The median length from the posterior pole to the posterior point of insertion of the DO tendon was 10 mm. The width of tendon of insertion of the DO tendon was 3.25 mm.

CONCLUSIONS

In disorders involving the oculomotor nerve or the oculomotor nerve nucleus in the mesencephalon, the resultant strabismus is directed ventrolaterally. Based on the insertion of the superior oblique muscle in humans, we hypothesized that the DO muscle would likely explain the ventral deviation in disorders of the oculomotor nerve or its nucleus. In this study, the point of the insertion of the DO muscle tendon was posterior to the equator. Based on this anatomic location, unopposed function of the DO muscle would be expected to result in ventral deviation of the globe.

Evaluation of orbital disorders and cranial nerve innervation of the extraocular muscles

A wide range of orbital disorders, including an orbital mass, infection, inflammation, systemic disease, or intracranial lesions, may be encountered with imaging. Evaluation of orbital disorders requires the combination of accurate and relevant clinical information with an understanding of anatomy and pathologic processes. An imaging approach to an orbital differential diagnosis includes assessment for alteration of a normal orbital structure, a lesion that does not belong in the orbit, or alteration of the orbit from bone or periorbital disorders. This approach, combined with key elements of clinical history, leads to a narrower differential diagnosis and improved patient care.

Interpeduncular fossa lipoma: a novel cause of oculomotor nerve palsy in childhood

Oculomotor nerve palsy is a rare finding in children and, when reported, is most frequently either congenital or acquired from postnatal trauma, infection, aneurysm, or migraine. Intracranial lipomas also represent an uncommon finding in children, and although their development is not completely understood, they are now thought to be congenital in nature. Here, we describe the case of a 23-month-old boy presenting to the emergency department with left-sided, complete, pupil-involving oculomotor nerve palsy. On magnetic resonance imaging, he was found to have an intracranial lipoma of the left interpeduncular fossa. The patient had gradual and spontaneous improvement of symptoms, with complete resolution reported at the 4-month follow-up visit. However, a second magnetic resonance image at 6 months revealed that the lipoma did not change in size. To our knowledge, intracranial lipomas have been previously reported as a possible cause of partial oculomotor nerve palsy in only one adult and have never been reported in a child. In addition, we did not find any reports of intracranial lipomas as a cause of complete, pupil-involving oculomotor palsy, although they are known to cause other cranial nerve pathology. We conclude that intracranial lipomas, although rare, should be considered in the differential diagnosis for oculomotor nerve palsy in children. Further investigation is needed to determine the true incidence of this association.

Third cranial nerve palsy or pseudo 3rd nerve palsy of myasthenia gravis? A challenging diagnosis in systemic lupus erythematosus

Diplopia is frequently encountered in neurological practice and may occur as part of the clinical spectrum of 3rd cranial nerve palsy. Correct localization of the underlying problem is the first step in making an accurate diagnosis. Pathologies affecting the supranuclear structures, cranial nerves and nuclei, extraocular muscles and the neuromuscular junction may cause or simulate 3rd nerve palsy. We report a case of a patient with longstanding quiescent SLE who presented with sudden onset of diplopia and discuss possible aetiologies including ischemia, demyelination, neuromuscular conditions and medication-induced.